Ovid Technologies (Wolters Kluwer Health)

During the last 20 years several less-invasive anterior approaches to the lumbar spine have become standard, including the extreme lateral transpsoas approach. Although it is associated with a lower risk of vascular injury compared with anterior midline approaches, neuromonitoring is considered mandatory to avoid neurologic complications. Interestingly, despite neuromonitoring, the reported risk of neurologic deficits with the extreme lateral transpsoas approach is greater than observed with other anterior approaches. An alternative lateral, oblique, psoas-sparing approach, recently named the oblique lumbar interbody fusion, uses the anatomic pathway between the abdominal vessels anteriorly and the lumbar plexus laterally to decrease the risk of neurologic and vascular injury; however, as yet, little on this new approach has been reported. We asked: what proportion of patients experienced (1) perioperative complications (overall complications), (2) vascular complications, and (3) neurologic complications after less-invasive anterior lumbar interbody fusion through the oblique lumbar interbody approach at one high-volume center? We performed a chart review of intra- and perioperative complications of all patients who had undergone minimally invasive anterior lumbar interbody fusion through a lateral psoas-sparing approach from L1 to L5 during a 12-year period (1998–2010). During the study period, the oblique, psoas-sparing approach was the preferred approach of the participating surgeons in this study, and it was performed in 812 patients, all of whom are studied here, and all of whom have complete data for assessment of the short-term (inpatient-only) complications that we studied. In general, we performed this approach whenever possible, although it generally was avoided when a patient previously had undergone an open retro- or transperitoneal abdominal procedure, or previous implantation of hernia mesh in the abdomen. During the study period, posterior fusion techniques were used in an additional 573 patients instead of the oblique lumbar interbody fusion when we needed to decompress the spinal canal beyond what is possible through the anterior approach. In case of spinal stenosis calling for fusion in combination with a high disc space, severe endplate irregularity, or severe biomechanical instability, we combined posterior decompression with oblique lumbar interbody fusion in 367 patients. Complications were evaluated by an independent observer who was not involved in the decision-making process, the operative procedure, nor the postoperative care by reviewing the inpatient records and operative notes. A total of 3.7% (30/812) of patients who underwent the oblique lumbar interbody fusion experienced a complication intraoperatively or during the hospital stay. During the early postoperative period there were two superficial (0.24%) and three deep (0.37%) wound infections and five superficial (0.62%) and six deep (0.86%) hematomas. There were no abdominal injuries or urologic injuries. The percentage of vascular complications was 0.37% (n = 3). The percentage of neurologic complications was 0.37% (n = 3). The risk of vascular complications after oblique lumbar interbody fusion seems to be lower compared with reported risk for anterior midline approaches, and the risk of neurologic complications after oblique lumbar interbody fusion seems to be lower than what has been reported with the extreme lateral transpsoas approach; however, we caution readers that head-to-head studies will need to be performed to confirm our very preliminary comparisons and results with the oblique psoas-sparing approach. Similarly, future studies will need to evaluate this approach in terms of later-presenting complications, such as infection and pseudarthrosis formation, which could not be assessed using this inpatient-only approach. Nevertheless, with the results of this study the oblique psoas-sparing approach can be described as a less-invasive alternative for anterior lumbar fusion surgery from L1 to L5 with a low risk of vascular and neurologic damage and without costly intraoperative neuromonitoring tools. Level IV, therapeutic study.

Several studies have reported functional recovery of the shoulder after arthroscopic rotator cuff repair (ARCR). Preoperative estimation of the time required for functional recovery is important for determining surgical indications and for planning timing of the surgery and an appropriate postoperative physical therapy. We therefore asked: (1) how long it takes to obtain functional recovery after ARCR, and (2) what preoperative factors influence functional recovery time. We retrospectively evaluated 201 patients who had undergone ARCR. Using the Japanese Orthopaedic Association (JOA) shoulder scoring system, we defined the functional recovery period as the time required to achieve a score greater than 80% in each component. We evaluated the functional recovery periods and assessed preoperative influencing factors such as age, gender, shoulder stiffness, morphologic features of rotator cuff tears, and rotator cuff tear size. Sixty-three patients (31%) took less than 3 months, 81 patients (40%) took between 3 and 6 months, and 57 patients (28%) took greater than 6 months to achieve a score greater than 80% in each JOA shoulder assessment component. Younger patients without shoulder stiffness and with smaller rotator cuff tears had shorter functional recovery periods. One hundred forty-four patients (72%) obtained functional recovery within 6 months after ARCR. Age, shoulder stiffness, and rotator cuff tear size influenced functional recovery time. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of Clinical Orthopaedics and Related Research ®, the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system. The purpose of this article was to stratify the previously published standardized list of TKA adverse events and complications. A modified version of the Sink adaptation of the Clavien-Dindo Surgical Complication Classification was applied to the list of standardized TKA complications and adverse events. The proposed stratified classifications of TKA complications were reviewed and endorsed by the Knee Society. Stratification of TKA complications will allow more in-depth and detailed outcome reporting for surgeons, hospitals, third-party payers, government agencies, joint replacement registries, and orthopaedic researchers. This improvement in reporting of TKA complications will also improve the quality of orthopaedic literature.

The purpose of the present study was to assess whether clinicians are actually able to evaluate the mechanical status of fracture healing from radiograms. Fifteen orthopaedic surgeons evaluated the radiograms of experimentally produced femur fractures in rats and predicted mechanical strength (%) of the affected side compared to the unaffected control side. Following this, actual mechanical strength of the affected and control side was determined by a three-point bending test. The median of the strength in the transverse fracture model predicted from radiograms was 33% (2 weeks), 72% (4 weeks), 88% (6 weeks), 84% (8 weeks), and 89% (12 weeks). The actual measured recovery ratio of mechanical strength (exp/control × 100) was 36%, 76%, 93%, 89%, and 106% in each observation period respectively. The tendency was almost the same in a comminuted fracture model. The mean recovery rate determined by interpretation of the surgeons correlated linearly to the actual measured mechanical strength determined by mechanical testing (R2: 0.80 in transverse fracture, 0.60 in comminuted fracture). Clinicians demonstrated that a comparatively good evaluation of the mechanical status of fracture healing is possible from radiograms up to approximately 80% recovery. However, they tended to make less accurate, weaker assessments at the final stages. In conclusion, radiograms may be inadequate for evaluation of fracture healing completion.

Prior studies have suggested that Asian patients and women may be more likely to sustain atypical femoral fractures in association with bisphosphonate use. However, they do not account for confounders such as asymptomatic patients who are long-term bisphosphonate users or patients sustaining osteoporotic fractures. The purpose of this study was to determine the differences in sex and racial association with atypical femoral fractures by comparing demographic characteristics of patients who sustained an atypical bisphosphonate-associated fracture with patients on long-term bisphosphonates without fractures and with patients who sustained osteoporotic fractures. Three groups from prospective registries were identified: (1) patients with atypical femur fractures associated with long-term bisphosphonate use (BFF) (n = 54); (2) patients on long-term bisphosphonates but with no associated fractures (BNF) (n = 119); and (3) patients with osteoporotic proximal femur fractures not associated with bisphosphonates (PFF) (n = 216). Age, sex, and self-reported race/ethnicity were documented and compared. Multivariate and univariate analyses were done as well as age- and sex-stratified analyses. Age and sex distributions of the BFF and BNF patients were similar. There was a higher percentage of Asian patients in the BFF group (17%) than in the BNF group (3%; p = 0.004) as well as Hispanics (13% versus 3% in BNF; p = 0.011). Patients in the BFF group were younger than those in the PFF group (67.5 versus 78.4 years; p < 0.001) and had fewer males (7% versus 14%; p < 0.001). These data suggest that Asians are at higher risk for atypical bisphosphonate-associated fractures. We recommend closer followup in Asian patients who are taking bisphosphonates. Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

The FDA has approved recombinant human bone morphogenetic protein 2 (rhBMP-2) for treating acute, open tibial shaft fractures. However, the nature and frequency of complications after the use of rhBMP-2 in nonspinal orthopaedic surgery have not been well characterized. To determine what types of adverse events have been reported after the use of rhBMP-2, whether they were severe enough to require additional surgery, and after what types of operations these adverse events occurred. Adverse events reported to the FDA’s Manufacturer and User Facility Device Experience database were reviewed and summarized. Through December 31, 2011, the FDA has received 62 reports of adverse events involving rhBMP-2 in nonspinal orthopaedic procedures. Surgical site infections and other wound complications, heterotopic bone, pseudarthrosis, and local inflammation were among the most commonly reported adverse events. Almost half of the reports (30 reports; 48%) stated that the patients required secondary interventions to address the reported adverse events. The majority (49 reports; 79%) described adverse events occurring after unapproved uses, such as management of tibial plateau fractures, treatment of congenital pseudarthrosis of the tibia, and humeral reconstruction. Serious adverse events can occur after the use of rhBMP-2 in nonspinal orthopaedic procedures and may necessitate additional surgery. Most events in this analysis occurred after off-label uses. Postmarketing review of adverse event reports remains an important approach for identifying potential safety concerns.

The 5-year survival rates for localized liposarcomas reportedly vary from 75% to 91% with histologic grade as the most important prognostic factor. However, it is unclear which other factors, including the initial surgery quality and recurrent tumors, influence survival in localized liposarcomas (LPS). We analyzed factors (including AJCC staging system) influencing survival and local control of resectable LPS of the extremities/trunk wall and the impact of surgery quality and tumor status and type of disease recurrences according to pathological subtype. We retrospectively reviewed 181 patients with localized LPS: 110 were treated for primary tumors, 50 for recurrent tumors, and 21 for wide scar resection after unplanned nonradical resection. We determined survival rates and examined factors influencing survival. The minimum followup was 4 months (median, 52 months; range, 4–168 months). Five-year disease-specific (DSS), disease-free (DFS), and local relapse-free survival (LRFS) rates were: 80%, 58%, and 75%, respectively. Five-year local relapse-free survival rates for primary versus clinically recurrent tumor versus scar after nonradical resection were: 86.1%, 52.1%, and 73.3%, respectively. The following were independent negative prognostic factors for DSS (AJCC Stage ≥ IIb), DFS (Grade 3; clinical recurrence; skin infiltration), and LRFS (clinical recurrence; R1 resection). An unplanned excision, although influencing local relapse-free survival, had no impact on disease-specific survival (calculated from date of first excision 5-year rate of 80%, considering impact of combined treatment of clinical recurrence/scar). We confirmed the value of AJCC staging for predicting disease-specific survival in extremity/trunk wall LPS. Radical reresection of scar after nonradical primary tumor resection (+ radiotherapy) seems to improve disease-free and local relapse-free survival in liposarcomas. Patients with unplanned excision can be cured when referred to a sarcoma unit. Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence